Delayed maternal death after perimortem cesarean section

We report a case of perimortem cesarean section performed on a multigravida with congestive heart failure. This patient had a past history of repeated episodes of acute myocarditis and this time, congestive heart failure attacked her at the 36th week of gestation. The maternal condition deteriorated rapidly with frequent attacks of ventricular fibrillation and cardiac arrest, which gradually became unresponsive to active cardio-pulmonary resuscitation (CPR). The fetal condition also worsened accordingly. Cesarean section was therefore performed and a 2590 gm depressed female baby was delivered in less than one minute after skin incision and about twenty-seven minutes after the maternal condition became extremely unstable. The Apgar scores were 1 at one min, 4 at five min and 6 at ten min. The mother improved soon after delivery of the fetus and her consciousness returned. However, her condition deteriorated again and she died four hours after operation. The fetus survived and follow-up 21 months after delivery was normal.

Myocarditis and cardiotropic viral infection associated with severe left ventricular dysfunction in late-stage infection with human immunodeficiency virus

OBJECTIVES

The purpose of this study was to characterize the histologic and immunopathologic results of 37 endomyocardial biopsy samples from patients infected with human immunodeficiency virus type 1 (HIV-1) who were evaluated for unexplained global left ventricular dysfunction.

BACKGROUND

Recent studies have identified a growing number of patients infected with HIV-1 who develop unexplained left ventricular dysfunction and congestive heart failure. Myocarditis has been confirmed at autopsy in small numbers of such patients, although a pathogenic opportunistic infectious agent can rarely be identified.

METHODS

All patients had moderate to severe global left ventricular hypokinesia on two-dimensional echocardiography. Endomyocardial biopsy samples were evaluated by standard histologic studies, immunoperoxidase staining and in situ hybridization for cytomegalovirus and HIV-1 gene sequences.

RESULTS

Twenty-eight patients presented with New York Heart Association functional class III or IV congestive heart failure. Four patients had myocarditis secondary to known etiologies (opportunistic infection n = 2; drug-induced hypersensitivity myocarditis n = 2). Of the remaining 33 samples, 17 (51%) showed histologic evidence of idiopathic active or borderline myocarditis. Immunohistologic findings revealed induced expression of major histocompatibility class I antigen on myocytes and increased numbers of infiltrating CD8+ T lymphocytes. Specific hybridization within myocytes was observed in 5 of 33 samples with the HIV-1 antisense riboprobe and in 16 of 33 samples with the cytomegalovirus immediate early (IE-2) antisense riboprobe. All but one patient with specific myocyte hybridization presented with congestive heart failure; all patients had myocarditis and CD4+ cell counts < 100/mm3.

CONCLUSIONS

This study demonstrates that cardiotropic virus infection and myocarditis may be important in the pathogenesis of symptomatic HIV-associated cardiomyopathy.

Persistence of ventricular arrhythmia after resolution of occult myocarditis in children and young adults

OBJECTIVES

We sought to examine whether resolution of occult myocarditis in children with associated ventricular arrhythmia correlated with the presence of arrhythmia at late follow-up.

BACKGROUND

Complex ventricular arrhythmias have been documented in children with myocarditis. Therapy is aimed at controlling the arrhythmia and any associated ventricular dysfunction. However, no reported studies have documented whether resolution of myocarditis in children is associated with resolution of the associated arrhythmias.

METHODS

We performed a retrospective analysis of 12 patients (mean age 12 years) with myocarditis. Ambulatory electrocardiographic (Holter) monitors were reviewed for ventricular arrhythmias at presentation and follow-up. Patients were assigned to Group I if they received corticosteroids in addition to any antiarrhythmic agents and to Group II if they did not receive steroids. Follow-up endomyocardial biopsy was performed in some patients, and results were analyzed in relation to the presence of arrhythmias at follow-up.

RESULTS

Eleven patients had ventricular tachycardia, and one had multiform couplets. Corticosteroids were given to seven patients (Group I). Follow-up biopsy was performed in seven patients (six received steroids), with resolution of inflammation in all; four of the seven still had ventricular arrhythmias but with improved control. Of the five patients without follow-up biopsy, three had persistent arrhythmia. Absence of inflammation at follow-up biopsy did not correlate with loss of ventricular arrhythmias, and there was no difference between Group I and II patients with respect to resolution of arrhythmia (Fisher exact test, p = 0.70, power 11%).

CONCLUSIONS

Complex ventricular arrhythmias persist after apparent resolution of occult myocarditis in children. Although these arrhythmias are easier to control after such resolution, the patients may require long-term antiarrhythmic therapy.

Immunohistological characterization of infiltrating lymphocytes in biopsies of patients with clinically suspected dilated cardiomyopathy

Experimental and clinical data suggest a relationship between myocarditis and dilated cardiomyopathy. One postulated mechanism is a viral infection triggering a host response with autoimmune features directed against the heart, resulting in an initial myocarditis which is followed by dilated cardiomyopathy. Until now, the importance of myocarditis as an aetiological factor in the pathogenesis of isiopathic cardiomyopathy has been unknown. This investigation was undertaken to determine immunohistologically the frequency of lymphocytic infiltrations in endomyocardial biopsies of patients with clinically suspected dilated cardiomyopathy. T-lymphocytic subsets and other immunological features were also analysed to explore possible relationships between immunohistologically documented myocarditis and dilated cardiomyopathy.

Acute myocardial-infarction-like findings with myocarditis in infancy. A case report

A four-and-a-half-month-old infant suffered sudden circulatory collapse early in the course of a brief febrile illness. The electrocardiogram initially appeared normal; an abrupt change indicative of extensive myocardial infarction occurred following stabilization. Coronary arterial anatomy and flow by echocardiography and angiography were normal except for the finding of single origin of the entire coronary system from the left sinus of Valsalva. Gallium 67 myocardial imaging was positive for an inflammatory process, and the diagnosis of myocarditis was supported. This is the first case, to the authors' knowledge, of myocarditis simulating myocardial ischemia in an infant of an age in which anomalous origin of the left coronary artery from the pulmonary artery is a recognized cause for myocardial infarction.

Pericardioscopy and epicardial biopsy--new diagnostic tools in pericardial and perimyocardial disease

Pericardioscopy is a new diagnostic tool for macroscopic visualization of alterations in both the epicardium and pericardium. We report on 35 patients with pericardial effusion due to inflammatory perimyocardial disease. After puncture of the pericardial effusion, an 8F sheath was introduced over a guidewire under X-ray control. The pericardial pressures were measured; the fluid was removed by aspiration and exchanged with 100 ml of body-warm saline until the pericardial fluid was clear. To visualize the peri- and epicardium, for video- and photo documentation, two sorts of 8F endoscope were used, either a flexible fibreglass version or a rigid 110 degree one--both made by Storz. Cytology of the fluid and optically guided and controlled epicardial and pericardial biopsies were performed to classify the form of pericarditis. A specific diagnosis of viral pericarditis could thus be established in seven cases--by in situ hybridization for cytomegalovirus (n = 3) and by microneutralization test for enteroviruses and/or coxsackievirus B4 isolation (n = 4); of lymphocytic perimyocarditis in 16; of bacterial pericarditis in seven and antibody-mediated autoreactive pericarditis in five cases.

Prognosis in patients with diphtheric myocarditis and bradyarrhythmias: assessment of results of ventricular pacing

OBJECTIVE

To determine the prognosis in patients with diphtherial myocarditis and bradyarrhythmias and to assess the results of ventricular pacing in those with third degree atrioventricular block.

DESIGN

Case series.

SETTING

Referral department of cardiology in a teaching hospital.

PATIENTS

Twenty four out of 46 patients admitted with diphtherial myocarditis over 10 years had bradyarrhythmias. Six had sinus bradycardia, 15 atrioventricular or intraventricular conduction disturbances, and three atrioventricular dissociation.

MAIN OUTCOME MEASURE

Death rate.

RESULTS

Eleven patients died (46%): all seven patients with third degree atrioventricular block, the patient with bifascicular block, and three of the six patients with bundle branch block. Seven died of cardiogenic shock and four of ventricular fibrillation. All nine patients with sinus bradycardia or atrioventricular dissociation survived.

CONCLUSION

Conduction system disturbances in patients with diphtherial myocarditis are markers of severe myocardial damage and a poor prognosis. In addition, ventricular pacing does not improve survival.

Role of myocarditis in athletes with minor arrhythmias and/or echocardiographic abnormalities

We report the clinical and instrumental data, including the endomyocardial biopsy findings, of six young athletes presenting with minor arrhythmias and/or echocardiographic abnormalities. In one of them, a left ventricular dilation with moderate depression of the systolic function had been attributed to an athlete's heart. A diagnosis of arrhythmogenic right ventricular dysplasia had been made in three others, one with right ventricular dilation and apical hypokinesia, and two with ventricular arrhythmias with QRS morphology of left bundle branch block. A myocarditis could be unequivocally established in four athletes (two with and two without fibrosis). In the remaining two, with a clinical history strongly suggesting a previously acute myocarditis, the endomyocardial biopsy specimen revealed a nonspecific fibrosis compatible but not definitely pathognomonic of a healed myocarditis. Our report suggests that a myocarditis may be a cause of minor rhythm disturbances and/or echocardiographic abnormalities in athletes. A prevalent localization of the inflammatory process in the right ventricle with or without the occurrence of ventricular arrhythmias with left bundle branch block morphology can mimic an arrhythmogenic right ventricular dysplasia. An early diagnosis of myocarditis in athletes is useful to avoid the risk of fatal arrhythmias, also considering that rest still keeps on being one of the most effective strategies in myocarditis management.

Rat dilated cardiomyopathy after autoimmune giant cell myocarditis

One of the possible causes of dilated cardiomyopathy is considered to be a sequel to myocarditis. Two mechanisms have been proposed in the process of progression of myocarditis into dilated cardiomyopathy: one is a persistent viral infection, and the other is an autoimmune myocardial injury. To clarify the possible part played by the autoimmune mechanism in the process, using an animal model, we investigated whether autoimmune myocarditis, exclusively not related to viral infection, might develop into dilated cardiomyopathy. Experimental autoimmune myocarditis was elicited in Lewis rats by immunization with cardiac myosin fraction. Rats of the control group were immunized with ovalbumin. The clinical course was observed over 4 months. Six rats from the myosin-immunized group died during the acute phase and the healing phase, and all those rats had severe myocarditis. All rats that survived until the end of the study showed enlarged and discolored hearts. Aneurysmal changes were observed in the right ventricle during thoracotomy. The ratio of heart weight to body weight of the myosin-immunized group was significantly higher than that of the control group (3.36 +/- 0.49 versus 2.69 +/- 0.06 g/kg, respectively; P < .005). The lengths of the anterior interventricular fissure and the posterior interventricular fissure of the hearts of the myosin-immunized group were significantly longer than those of the control group. The external diameter of the left ventricle of the myosin-immunized group was also significantly larger than that of the control group. Diffuse myocardial muscle loss and replacement fibrosis were the prominent histological findings of the rats of the myosin-immunized group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Two cases of polymyositis with cardiac involvement]

Cardiac involvement in polymyositis is more prevalent than previously assumed. A 59-year-old and a 58-year-old man presented with cardiac involvement preceding skeletal muscular lesions, admitted because of increased levels of muscle-derived enzymes and left ventricular dysfunction with ECG abnormalities. Coronary angiography revealed no stenotic lesions. Right ventricular endomyocardial biopsy disclosed myocarditis. Left ventriculography showed local asynergy of cardiac wall motion. After admission the weakness and atrophy of skeletal muscles progressed gradually and high levels of muscle-derived enzymes persisted. Electromyography and skeletal muscle biopsy confirmed the clinical diagnosis of polymyositis. Both patients were diagnosed as having polymyositis with cardiac involvement, and treatment with steroids was started. Symptoms improved significantly, and the CK enzyme level was reduced effectively. The condition of one patient was well controlled, but the other suffered from repeated heart failure due to severe left ventricular dysfunction. The clinical spectrum of polymyositis is wide and variable. Further studies are needed to evaluate the detection, management, and prognosis of the disease as well as the pathogenesis and to prevent progression of cardiac involvement.

[Granulomatous gigantocellular myocarditis]

There was presented two case of granulomatous giant cell myocarditis in 21 and 41 year old women, who died of severe heart failure. There made clinical diagnose in both case of pulmonary embolism. Light microscopic examination showed diffuse damage to the myocardium with necrosis of myocytes, fibrosis, infiltration of lymphocyte, plasmocytes and number multinucleated giant cells. Other organs showed no evidence of granulomatous disease.

Orbital polymyositis and giant cell myocarditis

BACKGROUND

Orbital polymyositis associated with giant cell myocarditis rarely has been reported in the literature. The authors report the clinical, neuroradiographic, and histopathologic features of the only patient to survive this usually fatal syndrome after cardiac transplantation.

FINDINGS

This 22-year-old white woman presented in 1991 with periorbital redness, swelling, and pain in both eyes that was unresponsive to antibiotic therapy. Results of her examination were significant for limited extraocular movements, ptosis, erythema, edema, chemosis, and exophthalmos. Electrocardiogram and chest x-ray were normal. Orbital computed tomographic scan showed swelling of the extraocular muscles up to and including their insertions. The patient was given the diagnosis of orbital polymyositis and her condition improved clinically and radiographically while taking parenteral steroids. One month after discharge, the patient was in cardiogenic shock. Endomyocardial biopsy showed giant cell myocarditis, and the patient underwent emergent cardiac transplantation. Despite a complicated postoperative course, the patient has done remarkably well.

CONCLUSION

Although this disorder is rare, this case suggests the need for a high index of suspicion for giant cell myocarditis in patients with inflammatory orbital polymyositis. In non-Graves orbital polymyositis the patient should be questioned and instructed concerning the signs and symptoms of congestive heart failure. Chest x-ray, Holter monitoring, and electrocardiogram also should be performed and be repeated with an echocardiogram if there are any cardiac symptoms. In addition, early endomyocardial biopsy should be considered in the proper clinical setting, allowing timely diagnosis and expeditious cardiac transplantation.

Treatment of serious heart failure by transplantation in giant cell myocarditis diagnosed by endomyocardial biopsy

We describe a 47-year-old man who had rapidly progressive heart failure caused by giant cell myocarditis with no response to steroid therapy. A successful heart transplantation was performed after life-threatening arrhythmias. The diagnosis was made by endomyocardial biopsy before transplantation, and it was confirmed by the histologic condition of the recipient heart. The patient has been on a triple-immunosuppression therapy with no signs of rejection or recurrence of giant cell myocarditis 23 months after surgery.

Myocardial calcification: a predictor of poor outcome for myocarditis treated with extracorporeal life support

Myocarditis is an inflammatory disease of the myocardium with a variety of causes. It is potentially reversible, and has been treated successfully with extracorporeal life support (ECLS). With increasing severity, myocarditis results in significant damage to myocardial cells. Dystrophic calcification of the myocardium may occur, serving as a marker of severe damage. At the authors' institution, from July 1990 to January 1992, five patients (four neonates, one 5 year old) with severe myocarditis refractory to medical management were treated with venoarterial ECLS. Three survived (60%) and two died. All patients were female, and their age range was 2 weeks to 5 years. Nonsurvivors had significant myocardial calcification, which was detected by a chest roentgenogram as well as a two-dimensional echocardiogram; the three survivors had no evidence of calcification. The nonsurvivors had minimal recovery of myocardial function and subsequently had their ECLS discontinued at 83 and 169 hours, respectively. The authors conclude that the development of progressive myocardial calcification in conjunction with a lack of recovery of cardiac function is a sign of severe myocardial damage and poor prognosis. Continuation of ECLS in this setting may not be warranted.

Rhabdomyolysis with pericardial tamponade

A young man developed an acute illness and presented to the hospital in shock. On admission, both severe rhabdomyolysis and pericardial tamponade were present, the tamponade occurring as a complication of pericarditis. Echocardiography was required for rapid diagnosis of the cardiac tamponade. The etiology of this severe, life-threatening illness is discussed.

Clinical value of electrophysiologic study in patients with nonsustained ventricular tachycardia

Electrophysiologic study (EPS) was performed in 68 consecutive patients with nonsustained ventricular tachycardia (VT) detected by ambulatory monitoring. The study group consisted of 11 patients with coronary artery disease, 11 patients with idiopathic cardiomyopathy or myocarditis, 2 patients with valvular heart disease, 1 patient with post atrial septal defect repair and 43 patients with a normal heart. Syncope or presyncope was found in 34 percent of these patients. EPS was performed after all antiarrhythmic drugs were withdrawn for more than 5 days. Nonsustained VT, sustained VT, and ventricular fibrillation were induced in 21%, 4%, and 4% respectively. VT was induced more frequently in patients with organic heart diseases but it was not related to the history of syncope. Ejection fraction in the inducible patients was not different from that of the noninducible patients. During the mean follow up period of 31 months, there was no cardiac death. The results suggest that the prognosis of patients with nonsustained VT is good and the clinical significance of their EPS findings seems to be limited.

The causes of dilated cardiomyopathy: a clinicopathologic review of 673 consecutive patients

OBJECTIVES

The purpose of this study was to document the various causes of dilated cardiomyopathy in a large group of adult patients with congestive heart failure.

BACKGROUND

Previous reports of the causes of dilated cardiomyopathy have usually been case reports of a single specific etiology or review articles. The frequency of any single specific heart muscle disease is largely unknown.

METHODS

We evaluated 673 patients referred for congestive heart failure due to dilated cardiomyopathy. The evaluation included medical history, physical examination, routine blood chemistry and hematologic measurements, electrocardiography and echocardiography. Thyroid function tests, antinuclear antibody tests and urinary vanillylmandelic acid and metanephrine levels were also obtained. Endomyocardial biopsy with right heart catheterization was performed in every patient. Coronary arteriography was performed in patients who had at least two standard cardiovascular risk factors or a history suggestive of myocardial ischemia. The cases were retrospectively reviewed, and a final cause for dilated cardiomyopathy was listed for each patient.

RESULTS

The most common causes of dilated cardiomyopathy were idiopathic origin (47%), idiopathic myocarditis (12%) and coronary artery disease (11%). The other identifiable causes of dilated cardiomyopathy made up 31% of the total cases.

CONCLUSIONS

Idiopathic dilated cardiomyopathy is a common cause of congestive heart failure. Specific heart muscle diseases occur with much less frequency.

[A case of ruptured left ventricular aneurysm due to syphilitic myocarditis]

This case involved a 20-year-old male who on May, 14, 1992, lost consciousness while working and went into a state of shock. He was taken to a hospital, where cardiac tamponade was diagnosed. He was later transferred to this hospital. Based on the results of echocardiography, coronary arteriography and left ventriculography, a ruptured ventricular aneurysm was diagnosed. The patient underwent emergency surgery. Serologic tests for syphilis performed at admission were definitely positive. Histopathological examination of the wall of the ventricular aneurysm disclosed fibrous myocarditis and peripheral coronary endarteritis accompanied by infiltration of plasma cells and lymphocytes. Immunohistological study revealed treponeme in the histiocytes of the aneurysmal wall. The diagnosis was a ruptured ventricular aneurysm caused by syphilitic myocarditis. Since the advent of penicillin therapy, cardiovascular syphilis, particularly syphilitic myocarditis, has become a rare disease. The chief interest of this case is that treponeme was detected in the lesion of myocarditis.

Varied manifestations of viral myocarditis

Nine children in the age group of new born to 10 years were seen during the period October 1989 to January 1993 with varying manifestations of Myocarditis. This ranged from cardiogenic shock due to fulminant cardiac failure, recurrent wheezy episodes (mistakenly treated as bronchial asthma) bronchiolitis and rhythm disturbances. Clinical picture was collaborated by radiological evidence of cardiomegaly, ECG changes of low voltage QRS complexes with ST depression, T wave inversion or signs of left ventricular dilatation. SGOT, SGPT, CPK, LDH were elevated significantly in 7 cases. Echocardiographic changes ranged from left ventricular dilatation to global hypokinesia and mild mitral incompetence. Viral studies suggested infection with Coxsackie B1 in 4 cases, B4 in 2, B5 in 2 and Dengue 3 in 1 case. All the children recovered well with routine anti failure measures and treatment of arrhythmias and 2 children needed steroid therapy. At the end of follow up of 6 months to 1 year there has been complete reversal of ECHO changes to normal. Viral Myocarditis can manifest in varied ways in children and if treated adequately may lead to complete recovery.

An autopsy case of hypertrophic cardiomyopathy with pathological findings suggesting chronic myocarditis

Myocardial fibrosis in patients with hypertrophic cardiomyopathy (HCM) may play an important role in the function and/or dimensions of the left ventricle. We present an autopsied case of HCM followed for 10 years. A 68-year-woman with HCM underwent trans-aortic myectomy of the interventricular septum in 1979. A significant amount of round cell infiltration, myocardial fibrosis and disarray were observed in the resected specimen. She experienced repeated admissions due to diabetes mellitus and congestive heart failure, and died of renal failure in 1989. An autopsy revealed extensive myocardial fibrosis and significant cell infiltration in the ventricular myocardium. The infiltrating cells were almost all lymphocytes, and the ratio of CD4 to CD8 was 3.8. This ratio was different from that of typical viral myocarditis. This case suggests that there may be an undefined inflammatory process causing fibrosis in HCM, in addition to the ischemia due to intramural small coronary artery stenosis.